ASSESSMENT EXPLANATION PLANNING NURSING RATIONALE EVALUATION

OF THE INTERVENTION
PROBLEM
Subjective: ‘’lagi Deficient fluid STG: after 3hrs of -Assess precipitating -These will provide STG: after 3 hrs of NI,
akong nauuhaw at volume is the nursing intervention, factors such as other baseline data for patient will have
nagtatae din’’ decreased the patient have illnesses, new onset education once with verbalized
intravascular, verbalized diabetes, or poor resolved understanding of
Objective: interstitial, and understanding of compliance with hyperglycemia. causative factors and
-elevated intracellular fluid. causative factors and treatment regimen. Urinary tract infection purpose of individual
temperature of 38.4 C This refers to purpose of individual and pneumonia are therapeutic
-sweating of the skin dehydration, water therapeutic the most common interventions and
-thirst loss alone without interventions and infections causing medications.
-exhaustion change in sodium. medications. -Assess skin turgor, DKA and HHNS
-weight loss mucous membranes, among older clients. LTG: After 2 days of NI,
-dry skin or mucous LTG: after 2 days of and thirst. -To provide baseline the patient will have
membrane nursing interventions, data for further maintained fluid volume
the patient shall have comparison. Skin at a functional level as
maintained fluid turgor will decrease evidenced by individual
volume at a functional and tenting may good skin turgor, moist
level as evidenced by occur. The oral mucous membrane and
Nursing diagnosis: individual good skin -Monitor hourly intake mucous membranes stable vital signs.
Risk for Deficient turgor, moist mucous and output. will dry, and the client
Fluid Volume r/t membrane and stable may experience
inadequate fluid intake vital signs. extreme thirst.
as evidence by poor -Monitor BP especially -Oliguria and anuria
skin turgor. for orthostatic results from reduced
hypotension. glomerular filtration
and renal blood flow.
-Decreased blood
may be manifested
-Monitor respirations, by a drop in systolic
e.g acetone breath, blood pressure and
kussmaul’s orthostatic
respirations. hypotension.
-Acetone breath is
due to the
breakdown of
acetoacetic acid.
Kussmaul’s
espiration (rapid and
shallow breathing)
represent a
-Monitor laboratory compensatory
studies like; mechanism by the
blood glucose respiratory buffering
levels, system to raise
serum ketones, arterial pH by
potassium, exhaling more
sodium, carbon dioxide.
blood urea nitrogen -Elevated ketones is
and creatinine. associated with DKA.
-Monitor ABG for
metabolic acidosis.

-Insert dwelling
urinary catheter as -Clients with DKA
indicated have metabolic
acidosis with arterial
bicarbonate level
less than 18 mEq/L,
-Administer fluid as and a pH less than
indicated: Isotonic 7.30.
solution (0.9% NaCl) -To provide accurate
as ordered by the measurement or
doctor. urinary output
-Administer anti- especially for clients
pyretic as prescribed with neurologic
by the doctor. bladder.
-To replace
electrolytes, fluid loss
and prevent
dehydration.

-To decrease body

temperature and will
have less occurrence
of dehydration.
ASSESSMENT EXPLANATION OF PLANNING NURSING RATIONALE EVALUATION
THE PROBLEM INTERVENTION
S: “masakit ang tyan Acute pain provides a Short-term: Dx: To promote After the shift,
ko hanggang ngayon” protective purpose to Within 4 Assessed relief and wellness. the patient rated the
characterized by make the patient hours of providing location, Deep breathing pain scale of 4/10.
sharp pain; pointing informed and nursing interventions, characteristics, onset, exercises contribute
on the lower right and knowledgeable about the patient will be duration, frequency, to relief of pain
left quadrant, that the presence of an report reduced pain to quality, intensity, and To maximize
lasts for 3-5 minutes injury or illness. The a tolerable level. aggravating factors of opportunities for self-
when moving with the unexpected onset of pain. control over pain
pain scale of 7/10. acute pain reminds Observed manifestations.
the patient to seek evidence of pain. Only the
O: Patient is support, assistance, Edx: client can judge the
grimacing because of and relief. It has a Demonstrated level and distress of
pain with guarding duration of fewer than proper deep breathing pain; pain
behaviour; with JP 6 months. The exercise to relieve management should
drain; alert and physiological signs pain and suggested be a team approach
coherent. that occur with acute comfortable position. that includes the
pain emerge from the Instructed to client.
NURSING body’s response to report pain if not Necessary
DIAGNOSIS: pain as a stressor. tolerable by the for management of
Acute pain related to patient. underlying and
compression of nerve Interacted possible
ending related to with active complications
tissue trauma. communication to
divert pain.
With drainage
of 10ml from JP.